Medicaid Fraud Busters Look to Prevent Repeat Occurrences



Texas will try to make sure some dentists and orthodontists don’t try to pull any more Medicaid fraud.

The state hired a managed care firm to overlook all dental services provided in the state. Orthodontists now receive a flat payment for the work performed. The Texas Medicaid program now requires full dental molds to process a claim. The claims processing contractor also replaced the previous dental director. More orthodontists and staff have been added to cover all bases.

These sweeping changes were precipitated by the Medicaid payments Texas made two years ago. There was $185 million in reported Medicaid payments that year. The problem was that figure was more than the total the other 49 states combined spent on Medicaid.

This information led to an investigation in which it was discovered that people in Texas collectively don’t actually have teeth in that poor condition. Instead, some orthodontists were putting braces on children who didn’t them to drive up the cost of their Medicaid reimbursement payments—and making adjustments on the braces while keeping them on for an extended period of time.

Unfortunately for Texas, the figure in which the state has lost to fraudulent orthodontics is only a small portion of the total money Texas Medicaid loses. Nationwide, about $22 billion was lost last year due to improper Medicaid payments, according to some studies.

This national amount lost due to these fraudulent payments has declined in recent years, however. The percentage of Medicaid income lost due to fraud, abuse or other reasons was at 11 percent in 2008. In 2011, the figure was down to 8 percent. With more safeguards in place, widespread Medicaid fraud will likely continue to decrease.